, Volume 471, Issue 2, pp 655-664
Date: 24 Jul 2012

Surgeon Volume is Associated With Cost and Variation in Surgical Treatment of Proximal Humeral Fractures

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The issue of rising costs will likely dominate the healthcare debate in the forthcoming years.


We assessed factors including surgeon volume that were associated with lower hospital costs and variations in surgical treatment for proximal humeral fractures.


We used national databases for 2001 to 2008 to extract information on 25,731 patients undergoing surgery for proximal humeral fractures. We calculated hospital cost by converting hospital charges based on the hospital accounting reports collected by the Centers for Medicare & Medicaid Services.


In a multivariate linear regression analysis, higher surgeon volume, open reduction and internal fixation (versus hemiarthroplasty), and lower burden of comorbidities were associated with lower hospital cost. Higher surgeon volume was linearly associated with lower hospital costs such that, on average, adjusting for all other factors, a surgeon performing 20 shoulder arthroplasties per year saves a hospital approximately US $1800 per surgery. Factors associated with higher utilization of hemiarthroplasty included high surgeon volume (odds ratio [OR] = 1.46; 95% CI = 1.43, 1.97; as compared with low surgeon volume) and earlier years of our study period (OR = 0.61; 95% CI = 0.56, 0.66; for hemiarthroplasty in 2007–2008 versus 2001–2002).


Higher surgeon volume was associated with lower hospital costs for proximal humeral fractures. Therefore, policies on minimum volume requirements by hospitals may result in substantial cost savings. There is provider-based practice variation in the surgical treatment of proximal humeral fractures and evidence-based guidelines in this area are needed.

Level of Evidence

Level III, economic analysis. See Instructions for Authors for a complete description of levels of evidence.

One of the authors (NBJ) certifies that he, or a member of his immediate family, has received or may receive payments or benefits, during the study period, from National Institute of Arthritis and Musculoskeletal and Skin Diseases Project Number 1K23AR059199, Foundation for Physical Medicine and Rehabilitation (Rosemont, IL, USA), and Biomedical Research Institute (Boston, MA, USA).
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.
This work was performed at Brigham and Women’s Hospital, Boston, MA, USA.